Sub-xiphoid ablation clamp and method of sub-xiphoid ablation

ABSTRACT

Device and method for sub-xiphoid ablation of patient tissue. A sub-xiphoid access clamp has a handle, an elongate neck coupled to the handle and first and second opposing jaws. The first and second opposing jaws have first and second opposing relief segments being generally co-planar and concave with respect to one another to form a void therebetween, and first and second opposing elongate ablation elements positioned along the first and second opposing jaws and distal of the first and second opposing relief segments relative to the handle. The first and second opposing jaws are articulate between a closed position and an open position to admit, at least in part, a second portion of tissue of the patient within the void created by the first and second opposing relief segments while the first portion of tissue is positioned between the first and second ablation elements in the closed position.

PRIORITY

This application is a Divisional of U.S. Ser. No. 12/769,345, filed Apr.28, 2010, entitled “SUB-XIPHOID ABLATION CLAMP AND METHOD OF SUB-XIPHOIDABLATION”, the teachings of which are incorporated herein by reference,and that claims the benefit of U.S. Provisional Application No.61/177,533, filed on May 12, 2009, entitled “TISSUE ABLATION CLAMP ANDMETHOD”.

BACKGROUND

Atrial fibrillation is a common cardiac condition in which irregularheart beats cause a decrease in the efficiency of the heart, sometimesdue to variances in the electrical conduction system of the heart. Insome circumstances, atrial fibrillation poses no immediate threat to thehealth of the individual suffering from the condition, but may, overtime, result in conditions adverse to the health of the patient,including heart failure and stroke. In the case of many individualssuffering from atrial fibrillation, however, symptoms affecting thepatient's quality of life may occur immediately with the onset of thecondition, including lack of energy, fainting and heart palpitations.

In some circumstances, atrial fibrillation may be treated through theapplication of defibrillation shocks. In cases of persistent atrialfibrillation, however, surgery may be required. A surgical procedureoriginally developed to treat atrial fibrillation is known as a “MAZE”procedure where the atria are surgically cut along specific lines andsutured back together. While possibly effective, the MAZE proceduretends to be complex and may require highly invasive access to thethorax. In order to reduce the need to open the atria, thermal ablationtools were developed to produce lines of inactive heart wall that mimicthe MAZE procedure. Such ablation tools commonly utilize radio frequency(RF) ablation devices to ablate and isolate tissue which may beresponsible for the improper electrical conduction that causes atrialfibrillation. One such location of tissue which may be responsible forimproper electrical conduction is at the junction of the pulmonary veinswith the left atrium where spontaneous triggers for initiation of atrialfibrillation have been found. Patients who suffer from a paroxysmal formof atrial fibrillation experience short, self terminating episodes ofatrial fibrillation. “Lone” atrial fibrillation occurs in patients whohave either few or no other significant cardiac diseases.

Access to the left pulmonary veins by an inferior approach may berelatively free from interference. However, ablation around the rightpulmonary veins may be relatively more complicated due to the presenceof the superior and inferior vena cava as well as by pericardial tissuecalled a pericardial reflection. Pericardial reflections stretch fromthe right pulmonary veins to the superior vena cava, from the rightpulmonary veins to the inferior vena cava, and the right superiorpulmonary vein the left superior pulmonary vein. These pericardialreflections may effectively block any ability to surround the rightpulmonary veins so as to ablate tissue in and around the right pulmonaryveins without first dissecting at least one, and generally two, of thepericardial reflections to physically permit access to an ablationdevice. Pericardial reflection dissection may be undesirable underminimally invasive access. A procedure requiring dissection of thepericardial reflections may significantly increase the time required todo the overall procedure and increase the risk of unintended tearing orperforation of the heart or extracardiac structures. Moreover, while theright pulmonary veins may be accessible from the inferior side of theheart, by a sub-xiphoid access procedure, the presence of the inferiorvena cava may make the ability to clamp an ablation device on the rightpulmonary veins difficult or impossible without constricting the flow ofblood through the inferior vena cava.

SUMMARY

A sub-xiphoid ablation clamp has been developed that allows for theablation of tissue on and around the right pulmonary veins in asub-xiphoid access procedure that may not require the dissection of anypericardial reflection and that may not obstruct blood flow through theinferior vena cava. In particular, a sub-xiphoid ablation clamp at theend of a malleable neck has ablation members arrayed along the jaws ofthe sub-xiphoid ablation clamp. One of the jaws may pass to the right ofthe inferior vena cava, with the other jaw passing to the left, untilthe ablation elements are positioned proximate the tissue to be ablated.A relief segment on each of the jaws creates a space such that when thejaws are clamped down for the ablation procedure a void is created inthe jaws into which the inferior vena cava may fit with at leastsufficiently little distortion to prevent a significant occlusion ofblood through the vein. In an embodiment, the sub-xiphoid ablation clampallows a unique method of clamping on the right pulmonary veins and alsoallows clamping on the left pulmonary veins without the need fordissection of any pericardial reflections.

In an embodiment, a sub-xiphoid ablation clamp for ablating a firstportion of tissue of a patient has a handle, an elongate neckoperatively coupled to the handle and first and second opposing jaws.The first and second opposing jaws have first and second opposing reliefsegments coupled to the elongate neck and being generally co-planar andconcave with respect to one another to form a void therebetween andfirst and second opposing elongate ablation elements positioned alongthe first and second opposing jaws and distal of the first and secondopposing relief segments relative to the handle, respectively, andconfigured to ablate the first portion of tissue positionedtherebetween. The first and second opposing jaws are articulate betweena closed position and an open position to admit, at least in part, asecond portion of tissue of the patient within the void created by thefirst and second opposing relief segments while the first portion oftissue is positioned between the first and second ablation elements inthe closed position.

In an embodiment, the first and second opposing jaws articulate proximalof the first and second relief portions relative to the handle.

In an embodiment, the first and second opposing jaws articulate distalof the first and second relief portions relative to the handle.

In an embodiment, the first and second opposing jaws each furthercomprise a first and second atraumatic tip, respectively.

In an embodiment, the first and second atraumatic tips are spherical.

In an embodiment, the first and second elongate ablation elements arepositioned, at least in part, on the first and second atraumatic tips,respectively.

In an embodiment, the sub-xiphoid ablation clamp further has an imagingmember associated with the first and second jaws.

In an embodiment, the imaging member has a light source.

In an embodiment, the first and second opposing jaws actuate along aplane defined by a plane formed by the first and second relief segments.

In an embodiment, the first and second opposing ablation elementsarticulate distal of the relief segments along a plane generallyorthogonal to the plane defined by the first and second relief segments.

In an embodiment, a plane of the first and second opposing ablationelements fixedly form a generally orthogonal angle relative to the planeof the first and second relief segments.

In an embodiment, at least one of the first and second jaws further hasan electrode.

In an embodiment, the electrode is configured to perform at least one ofpacing a heart of the patient and sensing a cardiac signal of the heartof the patient.

In an embodiment, the first portion of tissue is a right pulmonary veinof the patient and the second portion of tissue is an inferior vena cavaof the patient.

In an embodiment, the first and second relief segments are sized toadmit the inferior vena cava in the void formed by the first and secondrelief segments without substantially restricting blood flow through theinferior vena cava.

In an embodiment, method of sub-xiphoid ablation of a first vein of aheart of a patient uses a sub-xiphoid ablation clamp having first andsecond opposing jaws comprising first and second opposing reliefsegments being generally co-planar and concave with respect to oneanother to form a void therebetween and first and second opposingelongate ablation elements positioned along the first and secondopposing jaws and distal of the first and second opposing reliefsegments relative to a handle, respectively, and configured to ablatethe first vein positioned therebetween, wherein the first and secondopposing jaws are articulable. The method has the steps of approachingthe heart with the jaws of the sub-xiphoid ablation clamp from asub-xiphoid direction, positioning a second vein within the void formedby the first and second relief segments and the first vein between thefirst and second opposing ablation elements, clamping the first veinbetween the first and second opposing ablation elements whilemaintaining blood flow through the second vein and delivering ablationenergy to the first vein.

In an embodiment, the first vein is a right pulmonary vein and thesecond vein is an inferior vena cava.

In an embodiment, the sub-xiphoid ablation clamp further has anelectrode positioned on the sub-xiphoid ablation clamp to contact tissueof the patient when the ablation elements are in contact with the tissueof the patient, and the method further has the step of delivering pacingenergy to the heart of the patient to generate a result.

In an embodiment, the delivering ablation energy step is based, at leastin part, on the result.

In an embodiment, the sub-xiphoid ablation clamp further has anelectrode positioned on the sub-xiphoid ablation clamp to contact tissueof the patient when the ablation elements are in contact with the tissueof the patient, and the method further has the step of sensing a cardiacsignal from the heart of the patient.

In an embodiment, the delivering ablation energy step is based, at leastin part, on the cardiac signal sensed from the heart.

In an embodiment, the sub-xiphoid ablation clamp further has an imagingmember generating an output, and at least one of the approaching stepand positioning step are based, at least in part, on the output.

FIGURES

FIG. 1 is a view of the pericardial recess in which the posterior aspectof a human heart lays, also seen are the great vessels that attach tothe heart;

FIGS. 2a and 2b are side and top views of a sub-xiphoid ablationablation clamp;

FIGS. 3a, 3b, 3c and 3d are various views of a jaw structure of thesub-xiphoid ablation clamp;

FIG. 4 is an image of the sub-xiphoid ablation clamp in use on a heart;

FIG. 5 is a close-up image of the sub-xiphoid ablation clamp being usedas in FIG. 4;

FIG. 6 is a sub-xiphoid ablation clamp with an alternative jawstructure;

FIG. 7 is a sub-xiphoid ablation clamp with an alternative atraumatictip;

FIG. 8 is a cutaway drawing of a sub-xiphoid ablation clamp in use in apatient;

FIGS. 9-17 are a sequence of images of a sub-xiphoid ablation clampbeing used within a patient;

FIG. 18 is a flowchart of using the sub-xiphoid ablation clamp of FIGS.2a and 2b ; and

FIG. 19 is a flowchart of inserting the sub-xiphoid ablation clamp ofFIGS. 2a and 2b within a patient.

DETAILED DESCRIPTION

The entire content of provisional U.S. Provisional Application Ser. No.61/177,533, filed May 12, 2009 is hereby incorporated by reference.

FIG. 1 shows a posterior view of a diagram of the tissues and greatvessels extending posteriorly from the cast formed by the pericardialsac of the human heart 10. Superior vena cava 12 and inferior vena cava14 deliver de-oxygenated blood to the heart from the upper and lowerregions of the body, respectively. The two right pulmonary veins 16 andtwo left pulmonary veins 20, deliver oxygenated blood from the lungs tothe left atrium. Pericardial reflections 18 extend between superior venacava 12, inferior vena cava 14, right pulmonary veins 16 and leftpulmonary veins 20. A right pulmonic vein recess 21 is between the rightpulmonary veins 16, and a left pulmonic vein recess 22 is between theleft pulmonary veins 20. Superior sinus 23, transverse sinus 24, andpostcaval recess 25 are also identified.

FIGS. 2a and 2b show a side view and a top view, respectively, of anembodiment of sub-xiphoid ablation clamp 30 that permits a sub-xiphoidapproach to access heart 10, and right pulmonary veins 16 in particular,without dissecting pericardial reflections 16 or harmfully occluding orobstructing the blood flow through inferior vena cava 14. Handle 32allows for grasping, manipulation and use of sub-xiphoid ablation clamp30 by a medical professional. Grasping trigger 33 provides at least somecontrol and manipulation of sub-xiphoid ablation clamp 30, including, invarious embodiments, clamping and delivery of ablation energy. Neck 34may be elongate and malleable to assist in the positioning ofsub-xiphoid ablation clamp 30 in proximity of heart 10. In anembodiment, a flexible neck 34 may be a malleable corrugated tube. In anembodiment a tube having a wall thickness of approximately 0.016 inches(0.0406 centimeters) may provide torquability while giving neck 34malleability to be re-shaped. Jaw structure 36 is positioned at thedistal end of neck 34, and may include opposing jaws, ablation members,atraumatic tips and opposing relief sections to create a space to allowjaw structure to circumscribe or not fully clamp and occlude inferiorvena cava 14. Cord 37 is configured to be coupled to a source ofablation energy and a source of conductive fluid.

In various embodiments, neck 34 is selected based on patient physiologyand may be of a length adequate to perform a sub-xiphoid approach. Incertain embodiments, the length of neck 34 is from ten (10) centimetersto thirty-five (35) centimeters. In an embodiment, neck is approximately22.86 centimeters long. In an alternative embodiment, neck isapproximately 15.8 centimeters long. In various embodiments neck 34 hasa width from one-half (0.5) centimeter to two (2) centimeters. In anembodiment, neck 34 has a width of approximately 1.27 centimeters.

In various embodiments, sub-xiphoid ablation clamp 30 is angled atvarious locations in order to provide improved access for sub-xiphoidablation procedures. In various embodiments, a handle 34 is curved suchthat a primary axis of neck 34 is angled from approximately fifty (50)degrees to approximately sixty-five (65) degrees relative to a linetangent to apex 39 of handle 32. In an embodiment, the angle of neck 34to the line tangent to apex 39 is approximately fifty-seven (57)degrees.

FIG. 3a shows an embodiment of jaw structure 36, which is alsoillustrated in FIG. 3b in a complementary side view, in FIG. 3c in asecond, close-up side view and FIG. 3d in an end view. First elongatejaw 38 and second elongate jaw 40 oppose each other and are coupled topivot 41 about which each may be actuated from a closed position to anopen position and vice versa. First jaw 38 and second jaw 40 have firstablation member 42 and second ablation member 44, respectively. In theillustrated embodiment, first ablation member 42 and second ablationmember 44 (obscured in FIG. 3a ) provide for bipolar electrical ablationof tissue that has been interposed between the ablation members 42, 44.Opposing relief segments 46 and 48, coupled to jaws 38, 40 at junctions47, 49, respectively, create and define void 50 which may be sized tocircumscribe inferior vena cava 14.

In various embodiments, ablation members 42, 44 may be electrodes. Suchelectrodes may be designed for creating transmural lesions on heart 10and may also be designed to achieve visible surface lesions. Jaws 38, 40may be covered by sheaths that consist of silicone, polyvinylchloride,polyurethane, or similar materials. Alternatively, jaws 38, 40 may becoated with rigid polymeric materials such as polycarbonate oracrylonitrile butadiene styrene (ABS) plastic. In various embodiments,jaws 38, 40 are from approximately five (5) centimeters to approximatelyfifteen (15) centimeters in length. In an embodiment, jaws 38, 40 areapproximately eleven (11) centimeters. The electrically active parts ofablation members 42, 44 may be stainless steel hypo-tubes containedwithin lengths of porous polymer such as sintered ultra-high molecularweight polyethylene. The ablation members 42, 44 may be mounted inseating areas located on the clamping surface of jaws 38 and 40.

In various embodiments, the length of ablation members 42, 44 may befrom approximately three (3) centimeters long to approximately eight (8)centimeters long. In such embodiments, ablation members 42, 44 may beselected to extend proximate atraumatic tip 54 (FIG. 5). The length maybe selectable on the basis of the length of the lesion desired to becreated on heart 10. In various embodiments, a kit may be provided withmultiple jaw structures 36 with different length ablation elements 42,44 which may be selected and utilized based on the particular needs ofthe patient. In various embodiments ablation elements 42, 44 are betweenfive (5) and seven (7) centimeters long. In an embodiment, jaw structure36 has ablation elements 42, 44 having a length of six (6) centimeters.In an alternative embodiment, ablation elements 42, 44 are GEMINI®devices manufactured by Medtronic, Inc., Minneapolis, Minn. and have alength of 6.3 centimeters. In an embodiment, ablation members 42, 44 areformed from platinum flat wire wound into coils.

In an embodiment, relief segments 46, 48 define a length fromapproximately one (1) centimeter to approximately four (4) centimetersfrom neck 34 to jaws 38, 40, and may be selected based on the physiologyof heart 10. In particular, relief segments may be selected based, atleast in part, on a thickness of inferior vena cava 14 and a distancefrom inferior vena cava 14 and right pulmonary veins 16. In anembodiment, relief segments define a length of approximately 2.5centimeters. Relief segments 46, 48 may define void 50 having a widthfrom 0.5 centimeters to two (2) centimeters when jaws 38, 40 are in aclosed position. In an embodiment, relief segments 46, 48 define void 50having a width of approximately one (1) centimeter.

In an embodiment, jaws 38, 40 are curved having a radius of curvaturefrom approximately 2.0 centimeters to approximately six (6) centimeters.The radius of curvature of jaws 38, 40 may be selected based, at leastin part, on a physiology of heart 10 and the nature of the lesion soughtto be created. In an embodiment, the radius of curvature of jaws 38, 40is approximately 4.3 centimeters.

In further embodiments, jaws 38, 40 define an angle relative to theprimary axis of neck 34 and relief segments 46, 48. In variousembodiments an angle between jaws 38, 40 and the primary axis of neck 34is defined by the angle between the primary axis of neck 34 and a linetangent to jaws 38, 40 proximate junctions 47, 49. In variousembodiments, the angle between the primary axis of neck 34 and jaws 38,40 is between approximately ninety (90) degrees and approximately onehundred thirty-five (135) degrees. In such embodiments, the angle may beselected based, at least in part, on the anatomy of heart 10. In anembodiment, the angle between the primary axis of neck 34 and jaws 38,40 is approximately ninety-six (96) degrees.

In various embodiments, jaws 38, 40 in a fully-open position define awidth between tips 54, 56 from approximately 2.5 centimeters toapproximately 7.5 centimeters. In such embodiments, the fully-openposition may be selected based on a physiology of heart 10. In anembodiment, jaws 38, 40 in a fully-open position create a distance ofapproximately 5.6 centimeters between tips 54, 56.

Ports 52 may provide accessibility for various components which may beuseful in utilizing sub-xiphoid ablation clamp 30. In variousembodiments, electrodes may be placed in ports 52 for sensing ablationenergy delivered or underlying activity of heart 10. Location membersmay also be positioned in ports 52. Such location members may includelights, such as light emitting diodes, which may illuminate the tissuearound jaw structure 36. Such illumination may provide for both directvisual observation of patient tissue, or may backlight patient tissueinterposed between port 52 and the user of sub-xiphoid ablation clamp30. By backlighting, for instance, pericardial reflection 18, lightemitting diodes may give a user an approximate idea of the location ofjaw structure 36 relative to a desired location in heart 10. Alternativelocation members are also envisioned, such as radio frequencytransponders, Hall-effect sensors, and other broadcasting members andmechanical means.

In various embodiments, ports 52 may form the terminus of a lumen orpassage that leads back to handle 32. The lumen may allow for variousdevices to be advanced from the handle 32 to ports 52. Such devices mayinclude electrogram recording catheters, ablation catheters, pig-tailcatheters, or fiber-optic imaging conduits. In further embodiments,ports 52 may also contain one or more imaging devices such as chargecoupled devices (CCDs) to allow viewing of the anatomy of the patientfrom the tip of the ablation jaws.

In a further embodiment, light emitting diodes may be positioned inports 52. In an embodiment, one port 52 may incorporate a light emittingdiode while another port 52 incorporates a light intensity sensingdevice such as a photoresister, photovoltaic device, photodiode, orother light measuring detector which may provide information regardingthe intensity of light passing through tissue between the light emittingdiode and the light intensity sensing device. Such information may beused to refine a position the ablation members 42, 44 relative to heart10. In alternative embodiments, light emitting diodes or other lightemitting sources may be incorporated elsewhere on sub-xiphoid ablationclamp 30, including elsewhere on jaw structure 36 including on jaws 38,40 and on pivot 41, and on neck 34.

Tips 54, 56 of jaws 38, 40 may also include inflatable balloons that mayhelp to separate tissue planes when inflated, which may facilitateadvancement of sub-xiphoid ablation clamp 30 or provide space to improvevisualization of patient anatomy using line-of-sight or endoscopicvisualization, among various possible benefits. Such balloons may beelastic, compliant or non-compliant.

Tips 54, 56 may be configured to be atraumatic, reducing, at least inpart, trauma tissue tips 54, 56 create when they are utilized in thebody of the patient. In an embodiment, the tips cause no discernabletrauma to patient tissue at all. In the illustrated embodiment, tips 54,56 are bulbous, forming a generally spherical or hemispherical shape.The comparatively large cross section reduces stress on patient tissueinto which tips 54, 56 come into contact. In alternative embodiments,tips 54, 56 may be shaped in various other configurations which may beatraumatic to patient tissue. Such embodiments include helical ordouble-helical shapes, and shapes which are radially flared with respectto first jaw 38 and second jaw 40. Tips 54, 56 and jaws 38 and 40 may becoated with a lubricious coating such as polyacrylamide orpolyvinylpyrollidone or other such lubricious material to improvepassage through the anatomy. In an embodiment, shown with particularityin FIG. 3d , ablation elements 42, 44 extend onto atraumatic tips 54, 56in order to increase the size of the resultant lesion which may becreated.

Electrodes 58 may be utilized to provide cardiac pacing and cardiacsensing. Electrodes 58 are positioned on jaw 40 relative to ablationelement 44 such that when jaw 40 is in contact with cardiac tissueelectrodes 58 are distal of heart 10 relative to ablation element 44.When in contact with patient tissue, electrodes 58 may be coupled to asource of pacing energy and deliver pacing energy to the tissue, and aresult of the pacing energy on heart 10 noted. A response by heart 10 tothe pacing energy may be indicative of an incompleteness of a lesion inthe tissue due to the ability of the tissue to conduct energy.Similarly, if electrodes 58 are coupled to a cardiac signal sensingmodule, electrodes 58 may be utilized in sensing cardiac signals, thecontinued sensing of which may indicate an incompleteness of a lesion intissue due to the continued ability of the tissue to conduct electricalsignals.

As depicted in FIG. 3a , electrodes 58 are a relief which passes throughjaw 40 for purposes of installation of electrodes 58 during manufacture.After manufacture the reliefs may be hermetically sealed. FIG. 3bprovides an image of the electrically active contact points ofelectrodes 58. In the illustrated embodiment, positioning electrodes 58on jaw 40 may provide a user advantageous visual access of electrodes 58during ablation procedures. In an alternative embodiment, electrodes 58are positioned on jaw 38 rather than on jaw 40. In an alternativeembodiment, electrodes 58 are positioned on both of jaws 38 and 40.

Using jaw structure 36 with atraumatic tips 54, 56, it may be that nodissections of pericardial reflections 18 are necessary to placesub-xiphoid ablation clamp 30. In various embodiments, sub-xiphoidablation clamp 30 may be utilized to ablate both the right pulmonaryveins and the left pulmonary veins in various ablation procedures.

In various embodiments, jaw structure 36 is configured to rotate aboutpivot 41 when torque is applied to handle 32 while positioning theablation jaws. In various of such embodiments, pivot 41 may beselectively locked to limit or prevent rotation of jaw structure 36relative to handle 32. In such embodiments pivot 41 incorporates aconventional ball and socket hub or similar structure known in the art.Pivot 41 may be rotationally locked utilizing a manually inserted pin,by a control on handle 32, or by other method known in the art.

FIG. 4 shows an example of sub-xiphoid ablation clamp 30 being utilizedto ablate right pulmonary veins 16 of heart 10. Sub-xiphoid ablationclamp 30 circumscribes inferior vena cava 14 within void 50 created byrelief segments 46 (obscured), 48 in such a way that a real inferiorvena cava 14 might not be so occluded as to interfere the delivery ofde-oxygenated blood to heart 10.

FIG. 5 is a closer view of jaw structure 36 being utilized as in FIG. 4.Ablation members 42, 44 are in contact with the left atrial chamberwall, proximal to both right pulmonary veins 16. Atraumatic tips 54, 56may be in contact with right pulmonary artery 60 without exerting enoughforce to cause trauma to tissue. Embodiments in which ports 52incorporate electrogram recording electrodes are incorporated may beused to determine if the tips 54 have been advanced past the point ofcontact with the left atrial wall adjacent to the pulmonary veins 16.Embodiments which incorporate electrodes 58 may similarly be utilized toidentify a degree of contact with tissue of heart 10. When in contactwith the left atrium, a local electrogram may be sensed, while a localelectrogram may not be detected when ports 52 are in contact withpulmonary artery 60. Such a sensing system may afford confidence to theuser that the device has been properly placed on the intended anatomy.

FIG. 6 is an embodiment of sub-xiphoid ablation clamp 130 with analternative jaw structure 136. In contrast to jaw structure 36illustrated in FIG. 3, relief segments 146, 148 are at least partiallyproximal of pivots 141, 143 relative to handle 132. Void 150 may beconfigured to be sufficiently large to circumscribe inferior vena cava14 or large enough to allow a sufficient portion of the vena cava toremain open to blood flow. In utilizing an alternative embodiment of jawstructure 136, jaw structure 136 may be detachable at neck end 151, andmay be replaced by alternative jaw structures, for instance, jawstructure 36. In various embodiments, the dimensions provided bysub-xiphoid ablation clamp 130 are in accordance with the dimensions ofsub-xiphoid ablation clamp 30.

FIG. 7 illustrates an alternative atraumatic tip 154 of jaw structure136. Atraumatic tip 154 is configured to be flat, in contrast withbulbous atraumatic tip 54 of sub-xiphoid ablation clamp 30. Flatatraumatic tip 154 may provide an improved ability to dissect patienttissue when necessary and expedient to do so while still beingatraumatic during normal use. By providing a front edge 156 which has anedge, albeit a blunt edge, atraumatic tip 154 may be better configuredto cut through tissue than bulbous atraumatic tip 54.

FIG. 8 is an image of sub-xiphoid ablation clamp 30 in use in a cutawayrendering of patient 200. Preparatory to insertion of sub-xiphoidablation clamp 30 in patient 200, substernal incision 202 is created inpatient 200. Pericardium 204 is cut near diaphragm 206. Subxiphoidprocess 208 is cut near sternum 210. Once access is provided to heart 10sub-xiphoid ablation clamp 30 may be inserted for sub-xiphoid use. Themost direct path created by substernal incision 202, pericardium 204 andsubxiphoid process 208 results in inferior vena cava 14 being generallyobstructive of access to right pulmonary veins 16. As illustrated, jawsegment 36 circumscribes inferior vena cava 14 and clamps on rightpulmonary veins 16.

FIGS. 9-17 show a simulation of a sub-xiphoid approach and utilizationof sub-xiphoid ablation clamp 30 on a model of heart 10. In FIG. 9sub-xiphoid ablation clamp 30 approaches heart 10 with jaws 38, 40closed. In FIG. 10, as sub-xiphoid ablation clamp 30 nears heart 10 jaws38, 40 are opened. In FIGS. 11 and 12 jaws 38 and 40 pass on oppositesides of inferior vena cava 14. In FIG. 13 inferior vena cava 14 ispositioned at least in part within void 50 created by relief segments 46(obscured), 48 and jaws 38 (obscured), 40 are proximate right pulmonaryveins 16. FIGS. 14-17 show various viewpoints of heart 10 andsub-xiphoid ablation clamp 30 after sub-xiphoid ablation clamp 30 hasbeen positioned for ablation of tissue on and around right pulmonaryveins 16.

FIG. 18 is a flowchart of a method for ablating right pulmonary veins 16using sub-xiphoid ablation clamp 30. Jaw structure 36 of sub-xiphoidablation clamp 30 is inserted (1800) into the pericardial space of thepatient proximate heart 10. Jaws 38, 40 are maneuvered (1802) aroundinferior vena cava 14, so that one jaw 38 passes to one lateral side ofinferior vena cava 14 while the other jaw 40 passes to the other lateralside of inferior vena cava and inferior vena cava is generally betweenjaws 38, 40. Optionally, the user may identify (1804) a location of tips54, 56 utilizing equipment located in ports 52 such as light emittingdiodes, photosensors, cameras, and other equipment disclosed above.Locating the position of ablation elements 42, 44 relative to heart 10may provide greater assurance that right pulmonary veins 16 will beablated in contrast to other cardiac structures such as the rightpulmonary artery of the patient.

Jaws 38, 40 of sub-xiphoid ablation clamp 30 are positioned (1806)proximate right pulmonary veins 16, with one jaw 38 on one side rightpulmonary veins and the other jaw 40 on the opposing side of rightpulmonary veins. Jaws 38, 40 are closed (1808), bringing ablationelements 42, 44 into contact with right pulmonary veins 16. Ablationenergy is delivered (1810) to right pulmonary veins 16 in order tocreate the lesion.

FIG. 19 is a flowchart for a procedure which may be preparatory toimplementing the ablation method of FIG. 18. A patient is positioned(1900) on an operating surface. In various embodiments, the operatingsurface is part of a reclining table, examples of which are well knownin the art. The operating surface, and by extension the patient, isreclined (1902) from between approximately 10.0° and approximately35.0°. In various embodiments the degree of recline is selected in orderto give a medical professional a preferred sub-xiphoid angle of approachto heart 10. In an embodiment, the patient is reclined approximately20.0°.

Sub-xiphoid incision 202 is created (1904) in the skin of the patient,typically starting at the inferior aspect of the sternum and extendinginferiorly along the midline. In various embodiments initial sub-xiphoidincision 202 is wide enough to permit introduction of jaw segment 36 anda portion of neck 34 proximate heart 10. In various of such embodiments,jaws 38, 40 are in open position, while in other embodiments jaws 38, 40are in a closed position. In alternative embodiments, sub-xiphoidincision 202 is not initially large enough to permit introduction of jawsegment 36 and neck 34, and is instead large enough to allow theintroduction of cutting devices. In various embodiments, sub-xiphoidincision 202 is from approximately one (1) centimeter in width toapproximately 12.0 centimeters in width. In an embodiment sub-xiphoidincision 202 is approximately eight (8) centimeters in length.

After creation of sub-xiphoid incision 202, the pericardium 204 of heart10 is cut (1906) proximate the diaphragm 206 of the patient to createaccess to heart 10. Similarly with sub-xiphoid incision 202, the cut inpericardium 204 may be wide enough to permit passage through the cut ofjaw segment 36 and a portion of neck 34. As with the creation ofsub-xiphoid incision 202, in various embodiments the pericardial cut islarge enough to allow jaws 38, 40 to pass through in an open position insome embodiments and in a closed position in other embodiments. Thexiphoid process 208 of the patient is then removed (2208) proximate thesternum to improve access. In an embodiment, xiphoid process 208 isremoved as close to sternum 210 as may be safely attained. Inalternative embodiments, xiphoid process 208 is removed somewhat fartheraway from sternum 210, albeit still close to sternum 210. Once steps(1906) and (1908) have been performed, sub-xiphoid incision 202 may bespread (1910) if necessary to permit introduction (FIG. 18, 1800) of jawsegment 36 and neck 34.

Thus, embodiments of the invention are disclosed. One skilled in the artwill appreciate that the present invention can be practiced withembodiments other than those disclosed. The disclosed embodiments arepresented for purposes of illustration and not limitation, and thepresent invention is limited only by the claims that follow.

What is claimed is:
 1. A sub-xiphoid ablation clamp for ablating a firstportion of tissue of a patient, comprising: a handle; an elongate neckoperatively coupled to said handle and sized for insertion within saidpatient via a sub-xiphoid approach; first and second opposing jaws,comprising: first and second opposing relief segments coupled to saidelongate neck and being generally co-planar and concave with respect toone another to form a void therebetween; and first and second opposingelongate ablation elements positioned along said first and secondopposing jaws and distal of said first and second opposing reliefsegments relative to said handle, respectively, and configured to ablatesaid first portion of tissue positioned therebetween; wherein said firstand second opposing jaws are sized and shaped for insertion within thepatient via said sub-xiphoid approach and are configured to articulatebetween a closed position and an open position to admit, at least inpart, a second portion of tissue of said patient within said voidcreated by said first and second opposing relief segments in said openposition and maintain said second portion of tissue in said void whilesaid first portion of tissue is positioned between said first and secondopposing elongate ablation elements in said closed position.
 2. Thesub-xiphoid ablation clamp of claim 1 wherein said first and secondopposing jaws articulate proximal of said first and second opposingrelief segments relative to said handle.
 3. The sub-xiphoid ablationclamp of claim 1 wherein said first and second opposing jaws articulatedistal of said first and second relief portions relative to said handle.4. The sub-xiphoid ablation clamp of claim 1 wherein said first andsecond opposing jaws each further comprise a first and second atraumatictip, respectively.
 5. The sub-xiphoid ablation clamp of claim 4 whereinsaid first and second atraumatic tips are spherical.
 6. The sub-xiphoidablation clamp of claim 5 wherein said first and second opposingelongate ablation elements are positioned, at least in part, on saidfirst and second atraumatic tips, respectively.
 7. The sub-xiphoidablation clamp of claim 4 further comprising an imaging memberassociated with said first and second jaws.
 8. The sub-xiphoid ablationclamp of claim 7 wherein said imaging member comprises a light source.9. The sub-xiphoid ablation clamp of claim 1 wherein said first andsecond opposing jaws actuate along a plane defined by a plane formed bysaid first and second relief segments.
 10. The sub-xiphoid ablationclamp of claim 9 wherein said first and second opposing elongateablation elements articulate distal of said first and second opposingrelief segments along a plane generally orthogonal to said plane definedby said first and second opposing relief segments.
 11. The sub-xiphoidablation clamp of claim 9 wherein a plane of said first and secondopposing ablation elements fixedly form a generally orthogonal anglerelative to said plane of said first and second opposing reliefsegments.
 12. The sub-xiphoid ablation clamp of claim 1 wherein at leastone of said first and second jaws further comprises an electrode. 13.The sub-xiphoid ablation clamp of claim 12 wherein said electrode isconfigured to perform at least one of pacing a heart of said patient andsensing a cardiac signal of said heart of said patient.
 14. Thesub-xiphoid ablation claim of claim 1 wherein said first portion oftissue is a right pulmonary vein of said patient and said second portionof tissue is an inferior vena cava of said patient, and further whereinsaid first and second opposing relief segments are collectively sized toreceive said inferior vena cava in said void formed by said first andsecond opposing relief segments in said closed position of said firstand second opposing jaws without substantially restricting blood flowthrough said inferior vena cava.
 15. The sub-xiphoid ablation clamp ofclaim 1 wherein a plane defined by said first and second opposing jawsform an angle from approximately ninety degrees to approximately onehundred thirty-five degrees with respect to a primary axis of said neck.16. The sub-xiphoid ablation clamp of claim 15 wherein said angle isapproximately ninety-six degrees with respect to said primary axis ofsaid neck.
 17. The sub-xiphoid ablation clamp of claim 1 wherein saidvoid has a width orthogonal to an axis defined by said first and secondopposing elongate ablation elements when said first and second opposingjaws are in said closed position of between approximately 0.5centimeters and approximately 2.0 centimeters.
 18. The sub-xiphoidablation clamp of claim 17 wherein said width is approximately 1.0centimeters.
 19. The sub-xiphoid ablation claim of claim 1 wherein saidneck has a cross-sectional width of approximately 0.5 centimeters toapproximately 2.0 centimeters.
 20. The sub-xiphoid ablation clamp ofclaim 19 wherein said cross-sectional width is approximately 1.27centimeters.